UMBC Returning Student-Athlete Medical Update
2017- 2018
Please read through the following questions and answer as completely as you can with regard to changes incurred DURINGTHEINTERIM period from school.The information that is listed within this document will remain CONFIDENTIAL at all times. The purpose of this form is to assist the Sports Medicine Staff to determine if a potential risk exists for athletic activity.
Name: Current Medications:
Last 4 digits of Social Security # ______
Campus ID #: ______
Date of Birth: Sport: ______
______
Are you or have you ever been diagnosed with ADD/ADHD? Yes No
Have you had any major illnesses since the end of last season? Yes No
Have you had any injuries, accidents, or surgeries since the end of last season? Yes No
Have you been currently evaluated for any injuries or illnesses by a physician? Yes No
Would you like meet with the sports medicine team physician at this time? Yes No
Allergies
1. Have you experienced or had any problems with seasonal allergies? Yes No
2. Were you prescribed or currently taking any over the counter allergy medications? Yes No
3. Have you developed any new allergic reactions to any medications, food items, or insect stings? Yes No
Asthma
4. Were you recently diagnosed with asthma and/or exercise induced asthma? Yes No
5. Are you currently using an inhaler or asthma medication? Yes No
Cardiovascular
6.Have you ever passed out or nearly passed out DURING or AFTER exercise? Yes No
7. Have you had any chest pain, unexplained fatigue, or shortness of breath? Yes No
8. Were you seen by a physician or seek medical attention for any of the following:
Dizziness/Light-headednessHeart PalpitationsOther (Echo, EKG, stress test)
Light-headedness Heart Murmur
9. Have you ever felt your heart racing or skipping beats during or after exercise? Yes No
10. Do you get tired more quickly than your teammates/friends do during exercise? Yes No
11. Has a physician limited your activity for any cardiovascular reasons? Yes No
12. In the past year, have any family members been diagnosed with heart problems? Yes No
13. Has anyone in your family had unexplained fainting, unexplained seizures, or near drowning? Yes No
Heat Related Problems
14. Experienced any heat-related problems during training? Yes No
Head/Neck/Concussions
15. Have you suffered from any head or neck related injuries, including a concussion or stinger? Yes No
16. Have any of the following tests been performed for diagnostic purposes:
X-ray Neuropsychological TestingMRI
CT ScanOther
Eyes/Ear/Nose/Throat/Face/Dental
17. Have you experienced any injury to your ears, nose, throat, eyes, or face? Yes No
18. Any changes in your vision or hearing that required an assistive or corrective device? Yes No
(ie: contact lenses, glasses, hearing aids, etc.)
19. Have you suffered any injury to your jaw, mouth or teeth? Yes No
20. Have you had any surgery or medical procedure performed to the above body parts? Yes No
Abdomen/Ribs/Thorax/Chest
21. Have you experienced any injuries to the abdomen, ribs, thorax or chest? Yes No
22. Had any diagnostic tests performed to any of these body parts? Yes No
23. Had to seek medical attention for injury to any of these body parts? Yes No
Upper Extremity (UE)
24. Have you experienced any injuries to your LEFT/RIGHT shoulder? Yes No
25. Have you experienced any injuries to your LEFT/RIGHT elbow or forearm? Yes No
26. Have you experienced any injuries to your LEFT/RIGHT wrist, hand or fingers? Yes No
27. Have any diagnostic tests, including x-ray’s or MRI’s been performed on any part of the UE? Yes No
Low Back/Spine/Sacroiliac Joint
28. Have you experienced any injury to your low back, spine or sacroiliac joint? Yes No
29. Have you sought medical attention from a chiropractor or any other healthcare professional? Yes No
30. Have you gone to physical therapy for rehabilitation to any of the above body parts? Yes No
31. Had any diagnostic imaging performed including, x-ray’s, MRI’s, bone scan, other? Yes No
Lower Extremity
32. Suffered any injuries to the hip/groin/thigh/hamstring/quadriceps? Yes No
33. Have you suffered any injury to the knee or patella? Yes No
34. Have you suffered any injury to the lower leg, ankle, feet or toes? Yes No
35. Did you miss any time from training/competition due to injury to one of the above? Yes No
36. Were any diagnostic tests such as x-rays, MRI’s or bone scans performed? Yes No
37. Did you seek medical attention for any injury to the lower extremity? Yes No
38. Did you go to rehab or physical therapy for any injury to the lower extremity? Yes No
Additional Questions
39. Do you currently have an incompletely healed injury? Yes No
40. Do you currently have an ongoing/chronic illness? Yes No
41. Have you had a significant change in your weight (gain or lost) over the summer? Yes No
42. Do you limit the foods you eat? Yes No
43. Are you satisfied with your current weight? Yes No
- My playing weight last year was______
- My current weight is______
- My ideal weight would be______
44. Have you developed any altered eating habits or eating disorders? Yes No
45. Have you used any dietary supplements or laxatives to help you lose or gain weight? Yes No
46. Are you taking supplements of any kind on a regular basis? Yes No
47. Have you lost or gained weight to meet image requirements for your sport? Yes No
48. Does your weight affect the way you feel about yourself? Yes No
49. Have you recently been treated for depression or anxiety? Yes No
50. Have you been bothered by:
- Little interest or pleasure in doing things? Yes No
- Feeling down, depressed, or hopeless? Yes No
- “Nerves” or feelings of anxiousness or being “On Edge”? Yes No
- Feeling stressed or under a lot of pressure? Yes No
- Worry about a lot of things? Yes No
51. Have you recently experienced trouble sleeping or thought you had insomnia? Yes No
52. Have you been told you snore loudly or wake up often throughout the night? Yes No
53. Are you afraid of or are you being threatened by a current or former partner? Yes No
54. Within the past year, have you been hit, slapped, kicked, forced into sexual activity,
strangled or choked, or otherwise physically hurt by a current or former partner? Yes No
55. Do you feel you have a short temper or trouble controlling your emotions? Yes No
56. Have you recently developed a drug and/or alcohol concern? Yes No
Do you or has:
- Feel you need to cut down on your drug/alcohol use? Yes No
- Someone ever commented on your drug/alcohol use? Yes No
- Feel guilty about your drug/alcohol use? Yes No
- Require drugs or alcohol on a daily basis? Yes No
- Drink 5 or more drinks a day? Yes No
57. Are you currently under a physician’s care for any medical condition? Yes No
58. Are you currently under the care of a psychiatrist or psychologist or counselor? Yes No
59. Is there anything that was not asked above that you would like to discuss or any medical concerns that you may have heading into the upcoming school year?
Females Only:
Do you have monthly menstrual cycles? Yes No
How many menstrual cycles have you had in the last year? #:______
Do you use birth control (i.e. IUD, patch, pill, ring, etc…)? Yes No
Do you use birth control for a medical reason listed below:
Cramps Ovarian Cyst Irregular Periods Dermatological Hormonal Mood Stabilization
I, the undersigned, hereby acknowledge, affirm, and represent that all statements on the previous pages are true and accurate to the best of my knowledge; and that no answers or information have been withheld. If any information and/or statements are false and/or have been omitted in reference to my past and/or present medical history, I understand and acknowledge that my health and physical welfare may be jeopardized as a result and that I may suffer physical harm.
______Student-athlete Signature Date
______Student-athlete Print Name
______Parent/Guardian Signature Date
______
Parent/Guardian Print Name
______Witness Date
Sports Medicine Staff Reviewed By:
______
Reviewer’s SignatureDate
Last Updated 5/24/2017